Bsa Exemption Review Form – Fill Out and Use This PDF

BSA EXEMPTION REVIEW FORM					[ ] Initial Exemption [ ] Due Diligence or Annual Review
Company Name						Tax ID Number
Street Address						Account Number(s)
City, State Zip
Nature of Business

List trade name and street address of each business location depositing to and withdrawing from these accounts.

PHASE I EXEMPTION – LISTED ENTITY ON STOCK EXCHANGE OR SUBSIDIARY OF LISTED ENTITY If entity is listed on stock exchange or subsidiary of listed entity, complete this section. Otherwise, complete Phase II Exemption section below. BSA Department will document exemptions for banks and government agencies.

[

]

Company is listed on the following stock exchange: [ ] NYSE

[ ] NASDAQ

[ ] AMEX

Symbol

[

]

Subsidiary of

listed on [ ] NYSE

[ ] NASDAQ

[ ] AMEX

Symbol

Explain ownership:

PHASE II EXEMPTION – ELIGIBLE NON-LISTED BUSINESS

1.

Has U.S. customer maintained transaction account with the bank for at least 2 months?

[

] Yes

[ ] No

(STOP, customer is ineligible for exemption)

2.

Does customer frequently engage in currency transactions over $10,000 (at least 5 times per year)?

[

] Yes

[ ] No

(STOP, customer is ineligible for exemption)

3. Document business activities by GROSS REVENUES to insure eligibility for Phase II exemption. Tax Year

% Eligible Activities (i.e., retail merchandise sales, lodging, food, gas, etc.)

(If less than 51% of gross revenues, STOP, this customer is ineligible for exemption.)

%Ineligible Activities (Circle each activity that applies to this customer, cannot exceed 50%.) Lottery Sales (gaming of any kind other than pari-mutuel betting at racetracks); Purchase or sale of motor vehicles, farm equipment, vessels, aircraft, or mobile homes; Practice of law, accountancy or medicine; Auctioning of goods; Pawn brokerage;

Real estate brokerage; Title insurance and real estate closings; Chartering or operation of ships, buses or aircraft;

Investment advisory activities or investment banking services; or

Financial institution or agent of financial institution, including a money services business:

Check Casher; Currency dealer or exchanger;

Issuer of traveler’s checks, money orders or stored value;

Seller or redeemer of traveler’s checks, money orders or stored value;

Money transmitter or telegraph company; Casino or card club; or

Person subject to supervision of state or federal bank supervisory authority.

%Other

4.Does business cash checks, exchange currency or sell monetary instruments in an amount greater than $1,000

for any person on any day, in one or more transactions, or transmit money in any amount (other than as an agent for another business)?

[ ] No [ ] Yes (Submit evidence of Dept of Treasury and State registration as a money service business.)

Customer
Signature			Title			Date
BANK USE ONLY
Account Officer			Branch			Date

NOTE: Attach memo documenting on-site visit and evidence of registration as money services business. Forward to

BSA Department for review. Reminder: customer is not exempt until approved by BSA Department.	5/09